Friday 11 October 2013

A&E issues in Buckinghamshire


There are a lot of unhappy people in the south of Buckinghamshire, especially in the High Wycombe area.  They want their A&E and other hospital services back! The sad truth is that this is unlikely to happen.

As I have written about previously (What is happening to my hospital)  the A&E service closed down in 2005 and first there was the Emergency Medical Centre then in 2012 there was the Minor injuries and Illness Unit (MIIU). This must have felt like a downgrading of services each time there was a change.

The authorities did not do a good job in explaining the reasons for these changes to the residents of High Wycombe and the surrounding area.

As part of their inquiry into the actions being taken as a result of the Keogh inquiry into Buckinghamshire Healthcare NHS Trust the county Council health and social care select committee is going to examine the provision of A & E services.

I am predicting that they will say something along these lines:

  • Better facilities for A & E should be provided at Stoke Mandeville Hospital.
  • More permanent  Consultants, junior doctors and nurses in A&E are needed at Stoke Mandeville Hospital.
  • Better parking is needed  at Stoke Mandeville Hospital.
  • Better transport links (roads and public transport) between High Wycombe and Aylesbury are needed.
  • An effective and regular publicity campaign about the appropriate service to use (A&E, MIIU, Pharmacies, GP surgeries etc.) is needed.


They may use a few more words though.

See press articles

See Steve Baker MP for High Wycombe Blog

Communication

I love this quote:

Communication is primarily a function of trust, not of technique.  When the trust is high, communication is easy, it is effortless, it is instantaneous, it is effective - it works.

But when the trust is low and the emotional bank account overdrawn, communication is exhausting, it is terribly time consuming and its like walking in a minefield.

I wish I knew who said it?  so I googled it and ..........

 Stephen Covey, from The 7 Habits of Highly Effective People

Friday 27 September 2013

Conversations between patients and hospitals



Some hospitals and the newly created Clinical Commissioning groups are finding it difficult to engage in a meaningful and effective way with patients and the public. 

These are my thoughts on how they could hold a conversation with the public rather than 'engage' with them.

  • Go out to the people – don’t expect them to come to meetings.  It’s the same old faces, like me who go to public meetings.
  • Use language suitable for all
  • Keep it simple
  • Keep events small and short
  • Don’t give too much information at any one time
  • Leave time for reflection
  • Be prepared to repeat and revisit issues
  • Hold a conversation
  • Use patient leaders/champions
  • Feedback is essential. Explain how the input from patients has been used and has influenced change
  • Be informal, don’t lecture/broadcast.
  • Use staff, not managers/executives (?)
  • Be bold, take risks, do something different.
  • Social media is very powerful but it is a conversation. Those of us who use twitter get irritated if all we get are broadcasts and publicity messages. 


My questions at the AGM (Buckinghamshire Healthcare NHS Trust)

In the previous blog I gave my own highlights of the Buckinghamshire Healthcare NHS Trust AGM.

After the Chief Executive gave her presentation and the finance director gave his summary of the financial situation we heard from the leaders of the emergency surgery teams. They described how they had changed the service, what is called reconfiguration, and how the new service was producing better outcomes for patients & reducing mortality rates.  Good news.

At the end of the event there was time set aside for the public to ask questions.  I have no idea how many members of the public were present but I was virtually the only person who asked questions. 

Why is it that people don’t ask questions in formal board meetings?  I reckon most people know the answer to that one.

I asked a couple of questions:

The first was about the campaign to restore an A&E department to the High Wycombe Hospital site. A petition with 16,000 signatures has been organised.

There are 16,000 people in the south of the county who believe that there should be an A & E on the Wycombe Hospital site.

Can I ask that the Communications teams from the Clinical Commissioning Groups and the trust remind us, on a regular basis, about the good clinical, organisational and financial reasons why, in the present circumstances, there can only be one A & E in the county?

This is an on-going issue for those who live in High Wycombe.  The A&E department was closed in 2005 after a public consultation and replace with a minor injuries type of service.

As we know from other examples of such closures the local population is incredibly loyal to their local hospital. MPs too! So the story here is how to sell the difficult and complex reasons, hopefully evidence based, for such closures.

In my opinion the only way to tell the story is to keep it simple and be persistent.

However the audience was asked what else could be done to explain the reasons why there are only resources for one A&E department in the hospital.

My suggestion is that the leaders of the campaign should meet with senior clinicians and managers (and the commissioners) to have an informal, facilitated discussion and look at the evidence. 

As for how to improve the conversation between the hospital executives and the patients is something to explore in another blog.


*****************

The second question I asked was about the way they manage complaints.

Can I ask that the board measures its performance on managing complaints by using the following as outcome measures?

a)    Is the complainant satisfied at the end of the process
b)     has the trust learnt from the complaints  
c)    has the trust acted on the learning.

Normally the first thing that the board reports is that they replied to people within the required time. This is important of course, but I reckon that most people would say the best test of a good complaints service is: was I happy with the result?

  I hope that the trust may consider that a different approach will improve the way people think about the way complaints are managed.

They expressed some interest in this approach and said that they are trying to do something like this.  They have been contacting people by telephone after the complaint has been closed, especially complex complaints. But they have not been recording this activity. It sounds as if they are looking to improve the experience of complaining.


They did say that they get many more accolades than complaints. This is good to hear. 

Wednesday 25 September 2013

Buckinghamshire Healthcare NHS Trust AGM 2012/13

I realise that I have not written anything for my blog for a long time.  It has been a good summer so I have been otherwise engaged on holiday and working on my allotment.

I have just come back from our local hospital trust AGM.   This is a trust under special measures and heavily involved in the Jimmy Savile inquiry. Yet all is not lost –there is good news as well.

There was not a single case of MRSA during the year 2012/2013.  They recorded their lowest number of C Diff infections ever. – down by 50%.

The Hyper-acute Stroke Unit is the best in the region according to the Royal College of Physicians.

The hospital and the spinal injuries centre were at the centre of the Paralympics opening ceremony. A statue of Sir Ludwig Guttmann has been installed in front of the Spinal Injuries Centre

Three members of staff received national awards during the year.

In the first quarter of 2013/2014 even the HSMR has dropped below 100, it is now 97!

As the Chief Executive, Anne Eden, said “It was the best of times and the worst of time”.

The hospital had over a million contacts with patients and 5770 babies were born.

There have been service development and a £5M capital investment in A&E is being undertaken.

As part of their response to the Keogh report they have started  an “Every Patient Counts” action plan designed to improve services.

But the future is challenging as the health and social care economy has been under stress for many years and will be even tougher in future years. The CCG which is a major contributor to the income of the hospital is looking at a shortfall in its budget next year. There are difficult decision to be made in this year’s commissioning round which starts now.

The cost of the staff in the hospital accounts for 59% of the total expenditure of the trust.

There was a presentation by the emergency surgery team on how they have been redesigning the way in which they manage things.  They admit 3800 patients a year of whom 500 are over 80 years of age.  They see three times that number altogether.

I found it a bit confusing when they talked about emergency surgery that does not need to be done that day and the fact that their patient could be reasonably well.  Some patients can even stay at home.   This is obviously a version of ‘emergency’ that is new to me.

It was amusing to hear surgeons talking about holistic care!

The CE presented some internal awards to staff who had “Gone the extra mile” for patients.   These were people nominated by their colleagues and patients and from the hundreds of nominations a small number were selected.  They were both clinical and non-clinical staff and it was a nice way to end the formal part of the event.  Congratulations to those who received an award.



There was a final event when the statue of ‘Poppa’ Ludwig Guttmann was formally donated to Stoke Mandeville Hospital by the charity that had raised the money for it and other projects. http://www.poppaguttmanncelebration.org/


At the end of the meeting there was time reserved for the audience to ask questions.  I will discuss what happened then in the next blog. 

Sunday 24 February 2013

A story of a hospital - high mortality rates

It has not been an easy time for hospitals in Buckinghamshire.  Not that it has been easy for any hospital recently.

In 2005 two previously independent hospital merged to become the Buckinghamshire Hospitals NHS Trust.  One was Stoke Mandeville Hospital in Aylesbury and the other was Wycombe General Hospital in High Wycombe, 18 miles away on the other side of the Chiltern Hills.  Suddenly the management team had to look after three sites, three PFIs and work with a Primary Care Trust that was struggling to keep within budget. The budget was one of the lowest per head in England.

In 2005 the trust closed down the A&E in Wycombe and created a minor injuries unit, much to the disgust of the local population.  Trauma services were also moved while earlier the consultant led maternity unit and children's services had also been moved.

In 2010 the trust took over the management of community services, previously managed by the PCT.

In 2012 there was a big reconfiguration of services with some moving to one hospital and others being centralised at the other. So Wycombe Hospital now has a very good Hyper Acute Stroke Unit and a cardiology department while inpatient care for emergency medicine, respiratory, gastroenterology and medicine for older people have all moved to Stoke Mandeville Hospital.

Two mergers and a major reconfiguration within 5 years must have an effect on the effectiveness of a hospital. 

At the same time as all this merging and shifting of services, not forgetting the scandals & investigations, the trust has been trying to become a Foundation Trust. 

There is more!

 Now it is one of the hospital trusts being investigated for high mortality rates.

According to the data from Prof Brain Jarman's website http://brianjarman.com  trust has been reporting higher than expected death rates in 9 out of the last 11 years. The last four years have been higher than 110. So now they will be investigated by the Department of Health.

The trust, now called the Buckinghamshire Healthcare NHS Trust, has said that it has been examining the deaths of patients for the last 2 years in an effort to understand why the rates are so high. See their press release here

The trust  has in the past been quite successful in improving the quality of care it provides. Following the hospital acquired infection outbreaks the board saw the Infection Control reports at every board meeting. Now the trust is one of the better performing trust in this area.

Yet after two years of an in-house investigation the mortality rates are still high. Why?

What could be the causes for the high death rates. The Francis report on the Mid Staffs high death rates found that there were many causes but meeting targets, keeping to budget and getting foundation status were some of the primary causes.

In Buckinghamshire the health and social care economy has been under stress for many years. There have been the merger of the two hospitals and then the integration of the hospital and community services. There has been the Foundation Trust application. 

Is the fact that the PCT has been managing referrals and diverting patients to alternative providers before referring to the hospital meant that patients are sicker when they do get into the hospital?

Is it that they have been poor at coding patients in the correct way?  They have had two years at least to sort that one out. 

Is the reporting and analysis of the data flawed. Not so, says Prof Jarman and Dr Foster.

So is it that the hospitals are providing poor quality care?The patients are not reporting great concern, as far as I know, to the Trust, their GPs or the Local Involvement Network, or even Patients Opinion.

So what is happening  here? Why are the mortality rates still so high?

When will the investigation start and who will be on the team representing local people?

We need a swift and effective investigation so that the patients and the public can be re-assured that the trust is providing good quality care and is a safe place for us to go to when we need to use the hospitals

A story of Stoke Mandeville Hospital

This is a story about my local hospital. Well, its more of a history than a story.

It is quite well known.  Famous almost.  The original hospital, built in 1940 for casualties from the war, consisted of two long corridors of pre-fabricated wooden huts. It was not meant to last long.  My father-in-law tells the story of coming out to the site as a quantity surveyor to cost a tender for building it. (They did not get the tender.) It was green field site then, outside the small market town of Aylesbury. 

Those original wooden wards stayed with us until the new PFI funded hospital was built recently.  There were miles of corridors and there had to be two 'crash teams' as it took so long to get to the wards in an emergency.

I can see the hospital from my house.  I have been a patient there and I even worked there for a while.   I was a patient on the famous wooden wards.  When I was on the local Community Health Council we campaigned for years for a new hospital.  We were pleased when the new one was built.  Little did we know of the consequences of the way it was funded.

So this is our hospital and we are proud of it.  It is Stoke Mandeville Hospital. 

You have probably heard of it. 

In 1944 Ludwig Gutttman came to work here and created a new way of treating patients with spinal injuries. An amazing man!

In 948 the first Stoke Mandeville Games were held and in 1952 they became the international games. Thus was born the Paralympic movement.

The National Spinal injuries Centre (NSIC) moved into a purpose built building in 1983.  One of the chief fundraisers for this great facility was Jimmy Savile.  This is another reason the hospital is famous as it is currently in the middle of an investigation into his activities while associated with the hospital.

The hospital has had more than its fair share of scandals. 

In 2001 the Chief Executive and Chairman resigned because the Waiting Lists were fiddled. 

In 2003 and again in 2005 it was at the centre of the hospital acquired infection outbreaks when over 30 people died in two C. Diff outbreaks.

Now, in 2013, it is one of the nine hospitals being investigated by the Department of health for high mortality rates.

Is it an unsafe hospital?  In the next blog I will write about the recent history of this famous hospital.

Saturday 23 February 2013

Healthwatch - enagaging with the public

Our band new Healthwatch Buckinghamshire recently advertised its first public meeting.

Here is part of the advert:

"Do you use any of the health and social care services in Bucks? Or do your friends or family use them?

Do you want to see them improved in some way? If so then this event is for you.

Healthwatch Bucks is the new consumer champion for our county. It will give users and communities a stronger voice to influence and challenge how health and social care services are provided in Bucks.

Come along to find out about Healthwatch, the concept, context, vision and structure. Find out about the many different ways that you could get involved. Together we can improve things – see where you fit in and how your contribution could make a difference.”   

It seems to me that the new organisation has not learnt the lessons from previous efforts to engage with the public on health care.  Public meetings do not work unless there is a specific topic of interest.  

If they want to engage with the public in a meaningful and effective way then they should hold meetings with clear objectives and achievable outcomes.  They need to think inventively and smarter.  They need to do things differently.

If they want to publicise the "concept, context, vision and structure' they could do that more effectively by circulating information by email, post or even using social media!

How about this as a topic for a meeting: What are your concerns about the high Mortality Rates at Buckinghamshire Healthcare NHS Trust? What are your experiences of being a patient at the hospitals?

That might create some interest and they could then show us how Healthwatch Buckinghamshire could influence the care provided locally and how we could provide input into the investigation.

So this is a plea to Healthwatch Buckinghamshire to do things differently. Be innovative. Be bold.

Monday 28 January 2013

What does a Clinical Commissioning Group do?

One of our local Clinical Commissioning Groups is asking for our help, as members of the public, to develop a clear, concise statement that describes what they do.

The PCT cluster organised a workshop and the outcome of that event was two statements.  We are now being asked to choose which one works for us.

Well, my  answer was that neither of them do it for me.

Here are their suggestions:

Statement 1: The clinical commissioning group is your GP practices and their teams, which are responsible for buying healthcare services and working with you to improve the health of our whole community.

Statement 2: The CCG is your local doctors, their teams and the public, identifying the community's health needs and buying services to meet them. Our aim is to improve health across the county.

So here is my version:

The CCG is an NHS organisation, led by some local GPs, which is responsible for making decisions , locally, about:

  • What healthcare is provided for you,
  • Where it is provided,
  • How much is provided,
  • And the standards of care provided.
What do you think?

Can you do better?


Thursday 24 January 2013

Who should decide what healthcare we get

On April 1st,  traditionally known as April Fools Day, the UK government is implementing a major change in the way that decisions are made about what healthcare is bought and provided for us.

They have decided that some local GPs should form groups to commission some of our healthcare.For more information on these groups, called Clinical Commissioning Groups, see my blog here.

But are GPs the right people for the job? Whether they want to do the job is another question of course? Many of them are against the idea.

The reality is that they will only be taking the big strategic decisions about commissioning and giving clinical advice on what works and what does not.  The real day to day work of managing the contracts and making sure that the providers, hospitals that is, do deliver the right services, at the right time, in the right place at the agreed quality will be done by another shadowy organisation, the Clinical Support Organisations.

Should we be giving this responsibility to the GPs? They will be doing the job part time, under resourced and with little training. Most of them would rather be seeing their patients back in the surgery.  Who will be seeing those patients while they are at meetings?

So who else could do this important job?

Social care is commissioned by managers in councils under the strategic guidance from our elected councillors.  Perhaps, as suggested by the Labour Party, healthcare could be commissioned in the same way.   The newly created Health and Wellbeing Boards, due to start work on April Fools Day, will have some say in the way our healthcare is provided anyway. The trouble is are councillors and their managers any good any good at commissioning social care? Do they have the resources and the skills to do healthcare as well as social care?

In the old days the NHS was run at a local, county level by Area Health Authorities, with GPs, consultants, managers and councillors on the board.

Then there was fundholding when a limited budget was given to each GP practice to use to buy outpatients appointments and planned operations.

Then Primary Care Trusts took over the job with a few carefully selected GPs to advise managers on what to buy.

Now its back to the GPs alone.

All very confusing and uncertain.

I have no ideas who should do this vitally important job for us. Will local councillors on the Health and Wellbeing Boards be better than the PCTs and the yet to be tested CCGs?

Finally where do we, as members of the public and all of us potential service users, get a voice in the decision making process?

Tuesday 22 January 2013

A Patient's Story

I walked to the shops this morning along  the icy pavements.  On the way I met an old friend and we stopped for a gossip. We used to work together in one of the GP surgeries I worked in. We are both retired now.  After chatting about the old days, as you do, she mentioned that she was just about to have an operation.

This is a short edited version of her story of the modern NHS.

Several years ago she began to have problems with a hand.  So she went to GP.  He said  "ermmm, don't really know what is the cause but perhaps its your neck" and sent her off to the physio.  She did all the exercises the physio suggested (and I believe her) and her hand didn't get better. So back to the GP. More watchful waiting.  Finally she got an appointment with a consultant.

"I think I may have to inject your neck" he says.

"Ohh no" says my friend "Not until you check out the hand properly to see if there is another cause.

He agreed in the end and sent her off for some investigations and scans etc. As usual there was a delay of a few weeks before the investigations and then another delays (months) before a follow-up appointment with the consultants.

Amazingly the results were there at the same time she was.  "errrmm" he said.  I am still not convinced.  But she persisted and he did another examination and then sent her for some nerve conduction tests.  Another delay before the tests were done.

Then another wait before a trip to the consultant, again with test results.

"Yes" he said  " you do indeed have what you thought you had".  "You need an urgent operation as the results are very bad".

Now you may think the story ends there.  But no!

The operation required is on the 'Low Priorities List' and will only be done under exceptional circumstances.  So the consultant and GP have to write to the Primary Care Trust asking for permission to add her to the urgent waiting list. So another delay while the letter is written and the Panel reviews the request.

Luckily the PCT agreed and she will be getting the operation next month.

However in the several years that this has gone on her condition has got so bad that the operation needs to be done urgently.  It also means that her other hand has been overused and she fears it is going the same way.

This is the modern NHS.

Long delays. Treatments being rationed. Patients suffering and conditions getting worse. New barriers such as Low Priority Lists and Exceptional Circumstances reviews.

This is not good enough!